Pharmaceutical compositions and uses for androst-5-ene-3beta, 17beta-diol

ABSTRACT

Androst-5-ene-3β,17β diol is used to treat or reduce the likelihood of acquiring osteoporosis or menopausal symptoms, or other diseases affected by estrogen receptor activity, and for conditions which respond well to DHEA treatment, but where a higher ratio of estrogenic to androgenic effects is desired. Combination therapies are included, as are kits and pharmaceutical compositions for providing the active ingredients of claimed methods and combinations.

BACKGROUND OF THE INVENTION

[0001] 1. Field of the Invention

[0002] The present invention relates to pharmaceutical compositions,kits and methods for preventing and treating reduced or imbalancedconcentrations of sex steroids and conditions which can respondfavorably to increased activity of androgens and/or estrogens. Theinvention utilizes androst-5-ene-3β,17β-diol (hereinafter 5-DIOL) orcompounds converted in vivo to 5-DIOL

[0003] 2. Description of the Related Art

[0004] 5-DIOL is a compound biosynthesized from DHEA through the actionof reductive 17β-hydroxysteroid dehydrogenase (17β-HSD) and is a weakestrogen. It has an 85-fold Lower affinity than 17β-estradiol (E₂) forthe estrogen receptor in rat anterior pituitary gland cytosol (Simardand Labrie, J Steroid Boichem., 26.: 539-546, 1987), further confirmingthe data obtained on the same parameter in human myometrial and breastcancer tissue (Kreitmann and Bayard, J. Steroid Biochem., 11: 1589-1595,1979; Adams et al., Cancer Res., 41: 4720-4926, 1981; Poulin and Labrie,Cancer Res., 45: 4933-4937, 1986).

[0005] At concentrations well within the range of the plasma levelsfound in adult women 5-DIOL enhances cell proliferation and progesteronereceptor levels in human mammary tumor ZR-75-1 cells which lack3β-hydroxysteroid dehydrogbenase/D5-D4 isomerase activity (Poulin andLabrie, Cancer Res., 45: 4933-4937, 1986) and increases theestrogen-dependent synthesis of the 52 kDa glycoprotein in MCF-7 cells(Adams et al., Cancer Res., 41: 4720-4926, 1981).

[0006] In general, it is known that the serum levels of DHEA and DHEA-Sdecrease with age and corresondingly, that there is a dramatic reductionin the formation of androgens and estrogens in peripheral target tissuesand a marked decrease in the biochemical and cellular functions inducedby sex steroids. As a result, DHEA and DHEA-S have been used in thetreatment of a variety of conditions which are associated with decreaseand/or imbalances in the levels of sex steroids. Recently, we have foundthat the serum levels of 5-diol decrease markedly with age.

[0007] Osteoporosis, a condition which affects both men and women, isassociated with a decrease in androgens and estrogens. Estrogens havebeen shown to decrease the rate of bone degradation while androgens havebeen shown to build bone mass.

[0008] Menopausal symptoms have also been associated wilt a loss ofestrogens, and low dose estrogen therapy is commonly used inperimenopausal and menopausal women to relieve vasomotor symptoms,urogenital atrophy, irritability, sleep problems, loss of energy,osteoporosis, and other symptoms associated with menopause.

[0009] In addition, breast cancer, cardiovascular disease, and insulinresistance have been associated with decreased serum levels of DHEA andDHEA-S and both DHEA and DHEA-S have been suggested to prevent or treatthese conditions. DHEA has also been suggested to have beneficialeffects in the treatment and/or prevention of obesity, diabetes,atherosclerosis, chemically-induced breast, skin, and colon cancer,autoimmune diseases, Alzheimer's disease, loss of memory, aging and tosupport energy, muscle mass, and longevity. Uses of DHEA as well as thebenefits of androgen and estrogen therapy are discussed in InternationalPatent Publication WO 94/16709.

[0010] DHEA and DHEA-S have been suggested to be better for thetreatment of these conditions than standard estrogen and androgentherapy since the action of DHEA and DHEA-S is targeted to the tissueswhich can convert DHEA and DHEA-S to specific sex steroids. However,high doses of DHEA are required to get the necessary estrogenic andandrogenic effects. Most importantly, the androgenic effects of DHEA arepredominant and therefore, for conditions in which a higher proportionof estrogens is desired or where androgenic side effects are a problem,especially in women, the present invention permits a better proportionof estrogenic versus androgenic effects.

SUMMARY OF THE INVENTION

[0011] It is an object of the present invention to providepharmaceutical compositions and kits which include 5-DIOL or prodrugsconverted thereto in vivo. In some embodiments, the pharmaceuticalcompositions consist essential of 5-DIOL.

[0012] It is also an object of the present invention to provide methodsof treating and preventinq imbalances or reductions in the levels of sexsteroid hormones (androgens and/or estrogens) raising 5-DIOL levels in apatient in need of such treatment or prevention.

[0013] It is a further object of this invention to provide methods of ortreating or reducing the risk of onset of conditions which respondfavorably to estrogenic activity, including vagina atrophy,hypogonadism, diminished libido, skin atrophy, urinary incontinence,lipid, and lipoprotein imbalance, atherosclerosis, cardiovasculardisease and symptoms of menopause (hot flushes, sleep disorders,Alzheimer's disease. Parkinson's disease, mental disorders, depression,loss of memory) by administering 5-DIOL. it is a further object of thisinvention to provide methods of preventing or treating conditions whichrespond favorably to androgenic activity, including breast cancer,ovarian cancer, endometrial cancer, diminished libido, skin atrophy,skin dryness, osteoporosis and symptoms of menopause by administering5-DIOL. A number of diseases that are affected by sex steroids (e.g.osteoporosis) respond favorably to both androgens and estrogens.

[0014] A patient in need of treatment or reducing the risk of onset of agiven disease is one who has either been diagnosed with such disease orone who is susceptible to acquiring such disease.

[0015] Except where otherwise noted or where apparent from context,dosages herein refer to weight of active compounds unaffected bypharmaceutical excipients, diluents, caries or other ingredients,although such additional ingredients are desirably included, as shown inthe examples herein. Any dosage form (capsule, tablet, injection or thelike) commonly used in the pharmaceutical industry is appropriate foruse herein, and the terms “excipient,” “diluent” or “carrier” includesuch non-active ingredients as are typically included, together withactive ingredients in such dosage forms in the industry. For example,typical capsules, pills, enteric coatings, solid or liquid diluents orexcipients, flavorants, preservatives, or the like are included.

[0016] The invention also includes use of an active agent in themanufacture of a medicament for treatment of a disease specified hereinas susceptible to that agent, or one component of a combination in themanufacture of a medicament for treatment of a disease, where thetreatment further includes another component of the claimed combinationtherapy.

[0017] It is an additional object of this invention to provide novelcontraceptive methods which include administering 5-DIOL.

[0018] 5-DIOL is a metabolite of dehydroepiandrosterone (DHEA). It hasnow been discovered that 5-DIOL has an unexpected variation (relative toDHEA) in its androgenic and estrogenic effects. In particular, 5-DIOL isfive-fold more estrogenic than DHEA while its androgenic activity isonly one- to two-fold higher than that of DHEA, thus giving anestrogenic to androgenic ratio of approximately 3.0 for 5-DIOL comparedwith DHEA. On the other hand, at higher doses, 5-DIOL produces maximaleffects less androgenic than DHEA. Thus, the relative estrogenic versusandrogenic effects of administering 5-DIOL lie more toward estrogeniceffect than does a corresponding dosage of DHEA. Therefore, a 5-DIOL isparticularly useful in treating and preventing conditions involving lowlevels of sex steroids where the estrogen level, in particular, hasfalled (i.e. more so than the androgen level). Indeed the invention isusefull wherever an estrogenic effect is desired to a greater extentthan is an androgenic effect. As explained below, 5-DIOL may beadministered alone or in combination with other theraeutic agents suchas antiestrogens, androgens, progestins, estrogens, DHEA, DHEA-sulfate,LHRH agonists or antagonists, inhibitors of 17β-hydroxysteroiddehydrogenase, aromatase inhibitors, inhibitors of gonadal sex steroidsecretion as part of a combination therapy.

[0019] In the context of the invention, any prodrugs of 5-DIOL may heused in place of 5-DIOL, including 5-DIOL-fatty acids, as these willalso increase the serum levels of 5-DIOL.

[0020] Other features and advantages of the present invention willbecome apparent from the following description of the invention whichrefers to the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

[0021]FIG. 1 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on theuterine weight in ovariectomized rats, an estrogen-sensitive parameter.Intact animals are used as additional controls. The compounds weredissolved in 50% ethanol—50% propylene glycol and were administered in0.1 ml on the dorsal skin area (2 cm×2 cm).

[0022]FIG. 2 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on the serumluteinizing hormone (LH) concentration in ovariectomized rats, a measureof androgenic and/or estrogenic effect. Intact animals are used asadditional controls. The compounds were dissolved in 50% ethanol—50%propylene glycol and were administered in 0.1 ml on the dorsal skin area(2 cm×2 cm).

[0023]FIG. 3 is a grpah of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on the serumDHEA concentration in ovariectomized rats. The compounds were dissolvedin 50% ethanol—50% propylene glycol and were administered in 0.1 ml onthe dorsal skin area (2 cm×2 cm).

[0024]FIG. 4 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on the serum5-DIOL concentration in ovariectomized rats. Intact animals are used asadditional controls. The compounds were dissolved in 50% ethanol—50%propylene glycol and were administered in 0.1 ml on the dorsal skin area(2 cm×2 cm).

[0025]FIG. 5 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on the serumandrostenedione (4-dione) concentration in ovariectomized rats, ameasure of androgenic and/or estrogenic effect. Intact animals are usedas additional controls. The compounds were dissolved in 50% ethanol—50%propylene glycol and were administered in 0.1 ml on the dorsal skin area(2 cm×2 cm).

[0026]FIG. 6 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on the serumtestosterone concentration in ovariectomized rats. Intact animals areused as additional controls. The compounds were dissolved in 50%ethanol—50% propylene glycol and were administered in 0.1 ml on thedorsal skin area (2 cm×2 cm).

[0027]FIG. 7 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on the serumdihydrotestosterone (DHT) concentration in ovariectomized rats. Intactanimals are used as additional controls. The compounds were dissolved in50% ethanol—50% propylene glycol and were administered in 0.1 ml on thedorsal skin area (2 cm×2 cm).

[0028]FIG. 8 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on theventral prostate weight in orchiectomized rats, a measure of androgeniceffect. Intact animals are used as additional controls.

[0029]FIG. 9 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on theseminal vesicle weight in orchiectomized rats, a measure of androgeniceffect. Intact animals are used as additional controls.

[0030]FIG. 10 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on theconcentration of the mRNA encoding the C1 component of prostatic bindingprotein (PBP-C1) in the ventral prostate of orchiectomized rats, ameasure of androgenic effect. Intact animals are used as additionalcontrols.

[0031]FIG. 11 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered percutaneously twice daily for 7 days, on the mRNAencoding the C3 component of prostatic binding protein (PBP-C3) in theventral prostate of orchiectomized rats, a measure of androgenic effect.Intact animals are used as additional controls.

[0032]FIG. 12 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered subcutaneously twice daily for 7 days, on theuterine weight in ovariectomized rats, a measure of estrogenic effect.Intact animals are used as additional controls.

[0033]FIG. 13 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered subcutaneously twice daily for 7 days, on the serumLH concentration in ovariectomized rats, a measure of androgenic and/orestrogenic effect. Intact animals are used as additional controls.

[0034]FIG. 14 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered subcutaneously twice daily for 7 days, on prostateweight in orchiectomized rats, a measured of androgenic effect. Intactanimals are used as additional controls.

[0035]FIG. 15 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered subcutaneously twice daily for 7 days, on seminalvesicle weight in orchiectomized rats, a measure of androgenic effect.Intact animals are used as additional controls.

[0036]FIG. 16 is a graph of the effect of increasing doses of DHEA or5-DIOL, administered subcutaneously twice daily for 7 days, on the serumLH concentration in orchiectomized rates, a measure of androgenic and/orestrogenic effect. Intact animals are used as additional controls.

[0037]FIG. 17 shows the plasma concentration of DHEA (ng/mL) (Y axis infunction of time (X-axis) after a single oral absorption of prodrugs ofandros-5-ene-3β, 17β-diol (150 μmol/rat) in male rats. In the box, AUC24 h of DHEA induced by these compounds is reported. EM-760dehydroepiandrosterone EM-900 androst-5-ene-3β, 17β-diol EM-1304androst-5-ene-3β, 17β-diol 3- acetate EM-1305-CS androst-5-ene-3β,17β-diol diacetace EM-1397 androst-5-ene-3β, 17β-diol acetate 17benzoate EM-1400 androst-5-ene-3β, 17β-diol dibenzoate EM-1410androst-5-ene-3β, 17β-diol dipropionate EM-1474-D androst-5-ene-3β,17β-diol dihemisuccinate

[0038]FIG. 18 shows the plasma concentration ofandrost-5-ene-3β,17β-diol (ng/mL) (Y axis) in function of time (X-axis)after a single oral absorption of prodrugs of androst-5-ene-3β,17β-diol(150 μmol/rat) in male rats. In the box, AUC 24 h ofandrost-5-ene-3β,17β-diol induced by these compounds is reported. EM-760dehydroepiandrosterone EM-900 androst-5-ene-3β, 17β-diol EM-1304androst-5-ene-3β, 17β-diol 3- acetate EM-1305-CSandrost-5-ene-3β,17β-diol diacetate EM-1397 androst-5-ene-3β, 17β-diolacetate 17 benzoate EM-1400 androst-5-ene-3β, 17β-diol dibenzoateEM-1410 androst-5-ene-3β, 17 β-diol dipropionate EM-1474-Dandrost-5-ere-3α,17α-diol dihemisuccinate

[0039] In Vivo Assays of Bioavailability of the Prodrugs ofandrost-5-ene-3β,17β-diol

[0040] 1) Principle

[0041] The assays of the bioavailability of prodrugs ofandrost-5-ene-3β,17β-diol were performed in male Sprague Dawley rats bymeasuring the plasma concentrations of the compounds after single oraladministration of the compounds.

[0042] 2) Animals and Treatment

[0043] Male Spracue-Dawley rats [Crl:CD(SB)2r] weighing 275-350 g wereobtained from Charles-River Canada Inc. and housed 2 per cage during theacclimation period and individually during the study period. The animalswere maintained under a regimen of 12 hours light; 12 hours dark (lightson at 08:00). Animals received certified Rodent feed (Lab Diet #5002,pellets) and tap water ad libitum. Rats were fasted (access to wateronly) starting on the evening prior to dosing.

[0044] Each compound to be tested was administered to three animals as asuspension in 0.4% methylcellulose by oral gavage at a dose of 150μmol/rat. One blood sample of ˜0.7 ml was collected from the jugularvein of rats under Isoflurane-induced anesthesia at 1, 2, 3, 4 and 7hours post-gavage. Blood samples were immediately transferred into arefrigerated 075 ml Microtainer containing EDTA and kept in an ice-waterbath until centrifugation at 3000 rpm for 10 minutes. Plasma separationwas performed rapidly (less than 50 minutes) after blood collection).One aliquot of 0.25 ml of plasma was then transferred into aborosilicate tube (3×100) and was rapidly frozen on dry-ice. Plasmasamples were kept at −80° C. until measurement of plasma concentrationof the sex steroid or sex steroid orecursors by GC-MS.

DETAILED DESCRIPTION OF THE INVENTION

[0045] It is believed that 5-DIOL may be used, in accordance wih theinvention, for the treatment of any disease known to respond favorablyto treatment with DHEA with the added benefits related to its morefavorable ratio of estrogenic versus androgenic activities and its lowermaximal androgenic activity relative to DHEA. Administering 5-DIOLdirectly in accordance with the invention, has a number of advantagesover administering DHEA, as discussed herein.

[0046] Applicant has discovered that 5-DIOL produces significantlydifferent androgenic and estrogenic effects than does DHEA. Inparticular, 5-DIOL is shown to produce less potential androgenic ormasculinizing effects for a given production of estrogenic effects thandoes DHEA. Therefore, 5-DIOL is particularly beneficial in treatingconditions which require estrogenic activity with minimal androgenicactivity. In fact, after menopause, women have a deficit of bothandrogens and estrogens although the ratio of estrogen/androgen is lowerthan before menopause. Women thus require a more favorableestrogenic-androgenic ratio to compensate the loss of estradiolsecretion by the ovaries. DHEA cannot compensate for this ovarianestrogenic deficit but will only replace the lowered secretion of DHEA-Sand DHEA by the adrenals.

[0047] In particular, the production of the active androgen DHT and isprecursor 4-dione by administering DHEA ranged, for increasing dosages,from 30 to 125% greater than obtained with 5-DIOL administration. On theother hand, a 50% greater production of testosterone was obtained withDHEA than by administering 5-DIOL. 4-dione is a steroid which is itselfa weak androgen but is particularly effeciently transformedintracellularly into the more potent androgens testosterone, and DHT.THe data shows that the maximum levewl of serun DHT reached after 5-DIOLwas less than half of the maximum level reached with DHEA, and that at arelatively low dosage levels, the androgenic effect of 5-DIOL reaches aplateau of maximum activity much lower than that achieved by DHEA.

[0048]FIGS. 10 and 11 confirm the relatively higher level of androgenicactivity of DHEA as compared to the activity of 5-DIOL. The data shows,depending on dosage, that DHEA is two to five times more potent than5-DIOL in stimulating prostate binding protein-C1 (PBP-C1) and prostatebinding protein-C3 (PBP-C3) mRNA levels. The levels of PBP-C1 and PBP-C3mRNA are particularly sensitive parameters of androgenic action and theconcentration of the mRNAs encoding these proteins is regulated byandrogens. Measurements of PBP-C1 and PBP-C3 mRNA levels are indicativeof the androgenic activity since androgens act at the transcriptionallevel to increase steady state levels of the mRNAs encoding the subunitcomponents of PBP.

[0049] Because both DHEA and 5-DIOL administered percutaneously havealmost identical effects on estrogenic parameters at a given dosage.DHEA produces two to three times more androgenic activity than 5-DIOLwhere equivalent estrogenic effects are provided.

[0050] It has also been found that a major difference between DHEA and5-DIOL is that oxidative 17β-HSD(s) which transforms(s) 5-DIOL into DHEAha an extremely low level of activity after systemic administration of5-DIOL (see FIGS. 3 and 4). On the other hand, the similar levels ofserum5-DIOL following administration of DHEA and 5-DIOL indicate thatthe reductive 17β-HSD has a relatively high level of activity. Inaddition, since no significant DHEA appears available to be transformeddirectly into 4-dione by 3β-HSD, following 5-DIOL administration,androstenedione must derive from the oxidation of testosterone. This isin agreement with the fact that levels of serum 4-dione, a highlyefficient precursor of androgens, are must lower after 5-DIOL treatmentthan after DHEA treatment.

[0051] Without intending to be bound by theory, it is believed that oneof the reasons DHEA produces a different androgenic response than does5-DIOL (at equal dosage) is that DHEA and 5-DIOL are metabolizeddifferently. 5-DIOL's metabolism (more so than DHEA's metabolism) leadsto less formation and/or more inactivation of certain steroids (e.g.testosterone and DHT) before they can exert androgenic activity. Thus,5-DIOL leads to lower exposure to these potent androgens than does anequal dose of DHEA where the oxidized steroids predominate as areservoir for formation of the active androgens.

[0052] Further, as shown in FIGS. 14 and 25, where both compounds wereadministered by the subcutaneous route for an assessment or maximalbioavailability, the stimulation of androgen-sensitive parameters by5-DIOL reached a plateau at a lower value than achieved with DHEA. It isthus clear that the difference of maximal androgenic activity of DHEAand 5-DIOL observed after percutaneous administration of the twocompounds (FIGS. 9, 9, 10, and 11) is not due to different rates ofabsorption through the skin.

[0053] In general, the estrogenic activities of 5-DIOL under conditionsof maximal bioavailability were shown to be grater than those of thesame doses of DHEA. In fact, after subcutaneous administration, 5-DIOLis about 5 times more potent than DHEA to stimulate uterine growth.Therefore, as discusssed above, at a dosage where the estrogenic effectsare the same, the androgenic effects produced by 5-DIOL will besignificantly lower than the effects produced by DHEA. Moreover, theandrogenic effects of 5-DIOL reach a plateau of maximal effect which issignificantly lower than the maximal stimulation achieved with DHEA.

[0054] As will be discussed in detail below, 5-DIOL can be administeredto treat or prevent conditions in patients who have insufficient levelsor imbalanced concentrations of sex steroids, namely androgens and/orestrogens. In particular, 5-DIOL is believed useful in treating andreducing risk of acquiring conditions which respond favorably toestrogenic activity and in which lower androgenic activity than providedby DHEA is desired. Because 5-DIOL is metabolized qualitatively to thesame sex steroids as is DHEA, 5-DIOL may be used for any purpose thatresponds favorably to DHEA, with the benefit of different androgenicversus estrogenic effects than would result from using DHEA. Where thedesired estrogen/androgen ratio lies between what is achievable withDHEA versus 5-DIOL, then a mixture of DHEA and 5-DIOL may be used toprovide the desired ratio.

[0055] Individuals who will benefit from treatment with 5-DIOL includeall those suffering from conditions treatable with DHEA, including thosewith abnormally low levels of 5-DIOL, estrogen, or androgen. Reducingthe risk of acquiring such conditions is also possible and therecommended 5-DIOL dosage and target serum levels is the same as for thetherapeutic uses of 5-DIOL herein. Individuals who could benefit fromthe invention can be identified by measring serum levels of 5-DIOL,DHEA, sex steroids and their metabolites (especially androsteroneglucuronide and androstane-3a, 17β-diol glucuronide for androgens andestrone-sulfate and estradiol-sulfate for estrogens) as described byBélanger et al., in Steroid Formation, Degradation and Action inPeripheral, Normal and Neoplastic tissues (H. Bradlow, L. Castagnetta,S. d'Aquino, L. Gogliotti, eds) Ann. N.Y. Acad. Sci. 586: 93-100, 1990.Serum IGF-1 levels can be measured as described (Furlanetto et al., J.Clin. Invest. 60: 648, 1977).

[0056] In accordance with one aspect of the invention, once thedeficiency or imbalance is determined, 5-DIOL is preferably administeredat a dosage sufficient to raise and maintain serum 5-DIOL,concentrations up to 3 times above the normal range of young adults.Serum concentrations of 5-DIOL between 4.0 nM and 10 nM for women and 10to 20 nM for men are perferred, e.g. 7.0 nM for women and 15 nM for men.Naturally, the attending clinician may raise or lower dosage based onpatient response which may vary significatnly. Intermittent orcontinuous administration of a progestin (e.g. medroxyprogesteroneacetate, 5-10 mg/day oally) may alleviate possible unwanted side effectson the endometrium of the 5-DIOL treatment in premenopausal women.

[0057] In some preferred embodiments, serum concentration is between 4.0and 7.0 or between 7.0 and 15 nM for women and men, respectively.However, for purposes of contraception or for prevention of ovarian oruterine cancer, concentrations up to 15 nM (e.g. between 10 and 13) maybe preferred for women. For contraception, an estrogen may be added(e.g. estradiol giving serum estradiol levels between 50 and 200nanograms per liter), and an added progestin may be particularlyappropriate. Preferred dosages discussed herein may be increased asappropriate to achieve desired serum concentrations, e.g. withvariations for individuals patient response as monitored by theattending clinician.

[0058] When 5-DIOL is administered by the percutaneous or transmucosaltechnique, the delivered dosage may be raised or lowered in known ways,i.e. by altering the location to which the lotion, ointment, cream, gelor patch is applied by altering the size of the surface area to which itis applied, by altering the concentration of the active ingredient, orby altering the vehicle or carrier. For example, increasing the surfacearea will normally increase the dosage of active ingredient delivered ifthe concentration of active ingredient remains constant. In the samemanner, dosage delivered increases with increased concentration ofactive ingredient in the delivery base, and decreases with decreasedconcentration. Dosage delivered into the bloodstream also varies in aknown manner with respect to the body region at which the transdermalpenetration system is applied to the skin. Changing the vehicle orcarrier can also alter the delivered dosage in known wags.

[0059] Preferably, serum 5-DIOL concentration is measured beforetreatment begins, and a dosage is selected to quickly raise serum 5-DIOLconcentration to the preferred target range between 4.0 and 10 nM forwomen and 10 to 20 nM for men. Subsequently, the patient is monitoredboth symptomatologically and by circulating 5-DIOL or sex steroidmetabolit concentrations to verify that the desired serum concentrationand symptomatic relief have been obtained. 5-DIOL is then maintained ata constant concentration in the circulation. For a typicalpostmenopausal patient for example, this dosage is the equivalent ofapplication of 400 mg of the 5-DIOL, as part of a 10 percent compositionin 50% ethanol—50% propylene glycol, to a 200 square centimeter area ofthe abdomen or thighs two times daily per 50 kg of body weight. If oraladministration is chosen, 500 mg should be administered twice daily per50 kg of body weight.

[0060] As used in the invention, 5-DIOL may be administered with orwithout additional carrier or diluent by the oral route but requires anadditional carrier or diluent when administered by the percutaneous ortransmucosal route. In a pharmaceutical composition for oraladministration, 5-DIOL is preferably present in a concentration between5 and 99% by weight relative to total weight of the composition, morepreferably between 50 and 99 percent, especially between 80 and 99percent.

[0061] When prepared for percutaneous administration, 5-DIOL ispreferably present in a concentration between 2 and 20% by weightrelative to the total weight of the composition, more preferably between5 and 15%, especially between 5 and 10%.

[0062] The 5-DIOL active ingredient may be obtained from Steraloids Inc.(P.O. Box 310, Wilton, N.H., 03086, USA). Preferred 5-diol prodrugs arethe two compounds set forth below, commercially available fromSteraloids Inc.

[0063] 5-DIOL may be administered alone or may be administered incombination with other active compounds, such as antiestrogens,progestine, androgens, estrogens, DHEA or DHEA-S, inhibitors of17β-hydroxysteroid dehydrogenase, aromatase inhibitors, LHRH agonists orantagonists and other inhibitors of gonadal steroid secretion. Both DHEAand 5-DIOL are metabolized to androgens and estrogens, but indifferentproportions. In addition, 5-DIOL possesses weak intrinsic estrogenicactivity. That, in conjunction with the different inherent action DHEAor 5-DIOL have on the androgen or estrogen receptor, is believed toimpart the different ratios of androgenic versus estrogenic activityprovided by 5-DIOL versus DHEA. It is not necessary to utilize onlyDHEA's androgen/estrogen ratio or only 5-DIOL's androgen/estrogen ratio.DHEA and 5-DIOL may be used together to provide an optimally effectiveandrogenic/estrogenic response ratio that is between the ratio for DHEAand the ratio for 5-DIOL. The relative amounts of DHEA versus 5-DIOL maybe varied depending on whether the desired androgen/estrogen responseratio lies closest to that of DHEA or to that of 5-DIOL.

[0064] For the treatment of breast cancer, endometrial cancer, ovariancancer, endometriosis or other estrogen-sensitive disease requiringblockade of estrogen formation and/or action, at least one of thefollowing, namely an antiestrogen, an aromatase inhibitor, an androgeniccompound, a progestin, an LHRH agonist or antagonist or anotherinhibitor of gonadal sex steroid secretion, an inhibitor of17β-hydroxysteroid dehydrogenase activity can be used in combinationwith 5-DIOL. 5-DIOL alone or with DHEA would provide the androgeniccomponent required to stimulate androgen-sensitive functions,particularly bone formation and inhibition of androgen-sensitive cancergrowth (e.g. breast and endometrial cancer. 5-DIOL could then be usedalone or in combination with any of the compounds mentioned above usefulin the combination. In some cases, DHEA in the absence of 5-DIOL couldbe used in combination with any of the compounds mentioned above.

[0065] In another embodiment, 5-DIOL is combined with an antiestrogen,which is preferably EM-800((−)-7-pivaloyloxy-3-(4′-pivaloyloxphenyl)-4-methyl-2(4′″-2(2-piperininethoxy)phenyl)-2H-benzopyran),ICI 182,780(7a-[9-4(4,4,5,5,5-pentafluoro-pentylsulphinyl)nonyl]oestra-1,3,5(10)-triene-3,17β-diol) or any other antiestrogen for the treatment of breast cancer,endometrial cancer, ovarian cancer, cardiovascular diseases,atherosclerosis, and other estrogen-sensitive diseases. Non-steroidalantiestrogens such as EM-800 tend to be selective estrogen receptormodulators which act as estrogen receptor antagonists in breast tissue,yet provide estrogen-like beneficial effects on cholesterol, lipids andatherosclerosis.

[0066] The dosage of 5-DIOL can vary. The blood level of 5-DIOL and ofother sex steroids and their metabolites is indicative of the adequatedosage taking into account individual variation in absorption,metabolism, and sensitivity of response. Preferably, the attendingclinician will, especially at the beginning of treatment, monitor anindividual patient's overall response and serum levels of 5-DIOL (incomparison to the preferred serum concentration discussed above), andmonitor the patient's overall response to treatment, adjusting dosagesas necessary where a given patient's metabolism or reaction to treatmentis atypical. For combination therapies, one approach would be to starttreating with 5-DIOL alone and to add the other compounds only ifnecessary. For treatment of breast cancer, endometrial cancer, ovariancancer, and endometriosis, treatment with artiestrcgen+5-DIOL orantiestrogen+5-DIOL+DHEA or antiestrogen+DHEA are startedsimultaneously. If DHEA androgen, progestin or estrogen is added,similar monitoring of overall serum levels, both of the activeingredients and androgenic or estrogenic metabolites is preferred duringearly stages of treatment and as judged useful by the physician at latertime intervals.

[0067] Treatment in accordance with the invention is suitable forindefinite continuation. It is expected that 5-DIOL treatment willusually simply maintain this natural steroid within a range of 4 to 10nM and 10 to 20 nM serum concentration for women and men, respectively.Undesirable side effects from sustained 5-DIOL treatment are expected tobe either minimal or nonexistent. Avoiding unlikely side effects fromsustained estrogen use may be achieved in ways already known to the art,for example, by intermittent (or in some embodiments continuous)administration of a progestin (e.g. medroxyprogesterone acetate) at adaily oral dose of 2 to 10 mg. Any androgenic side effects should beminimal due to the relatively low androgenic effects of 5-DIOL and thealready low levels of DHEA in most patients undergoing the method of theinvention (FIG. 18).

[0068] In order to facilitate the combination therapy aspect of theinvention, for any indication discussed herein, the inventioncontemplates pharmaceutical compositions which include both 5-DIOL and asecond or subsequent active compound(s) in a single composition forsimultaneous administration. The composition may be suitable foradministration in any traditional manner including but not limited tooral administration, percutaneous administration or transmucosaladministration. In other embodiments, a kit is provided wherein the kinincludes 5-DIOL and a second compound in separate containers. Additionalactive compounds discussed herein may also be included. In addition toother modes of administration, the second compound as well as 5-DIOL mayalso be administered transdermally in accordance with the invention asdiscussed in more detail below. Thus, the kit may include appropriatematerials for transdermal administration, e.g., ointments, lotions,gels, creams, sustained release patches and the like. The same strategyapplies to the progestin, antiestrogen, androgen, estrogen, DHEA,DHEA-S, inhibitor of 17β-hydroxysteroid dehydrogenase, aromataseinhibitor or inhibitor of genadal sex steroid secretion which can beadministered orally (or by injection for the LHRH agonist orantagonist).

[0069] Although, it is anticipated that in some circumstances 5-DIOL maybe administered by injection, this method is not favored. Sincetreatment with 5-DIOL will often be of prolonged and indefiniteduration, repeated delivery by injection is inconvenient.

[0070] It is believed that the preferred routes for therapeuticadministration of 5-DIOL are percutaneous, transmucosal or oral, sincethe discomfort and inconvenience of administering 5-DIOL by injectionare avoided.

[0071] Any of a number of art-recognized transdermal penetration systemsmay be utilized for the delivery of 5-DIOL. For example, 5-DIOL may beprepared as part of an ointment, lotion, gel or cream for rubbing onto apatient's skin or mucosa. The active ingredient is preferably presentfrom approximately 5% to 20% by weight relative to the total weight ofthe pharmaceutical composition and more preferably is betweenapproximately 5 and 12% weight. Alternatively, the active ingredient maybe placed into a transdermal patch having structures known in the art,for example, structures such as those set forth in E.P. Patent No.0279982.

[0072] When formulated as an ointment, lotion, gel, cream or the like,the active compound is admixed with a suitable carrier which iscompatible with human skin or mucosa and which enhances transdermal ortransmucosal penetration of the compound through the skin or mucosa.Suitable carriers are known in the art and include but are not limitedto Klucel HF and Glaxal base which is available from Glaxal CanadaLimited Company. Other suitable vehicles can be found in Koller andBuri, S.T.P. Pharma 3(2), 115-124, 1987. The carrier is perferably onein which the active ingredient(s) is(are) soluble at ambient temperatureat the concentration of active ingredient that is used. The carriershould have sufficient viscosity to mantain the precursor on a localizedarea of skin or mucosa to which the composition has been applied,without running or evaporating for a time period sufficient to permitsubstantial penetration of the precursor through the localized area ofskin or mucosa and into the bloodstream where it will cause measurableand desired increase in serum 5-DIOL concentration. The carrier istypically a mixture of several components, e.a. pharmaceuticallyacceptable solvents and a thickening agent. A mixture of organic andinorganic solvents can aid hydrophilic and lipodhilic solubility, e.g.water and an alcohol such as ethanol.

[0073] Desirably, the carrier is one which, if formulated as 10% 5-DIOLand 905 carrier (by weight) and applied twice daily in an amountproviding 100 mg of 5-DIOL to the abdominal area, will elevate serumconcentration of 5-DIOL in a typical patient by at least 1.0 nM per 50kg of body weight above serum levels prior to treatment, and thereaftermaintain relatively constant serum levels of 5-DIOL 5-DIOL.

[0074] The carrier may include various additives commonly used inointments, lotions, gels, and creams and well known in the cosmetic andmedical arts. For example, fragrances, antioxidants, perfumes, gellingagents, thickening agents such as carboxymethylcellulose, surfactants,stabilizers, emollients, coloring agents and other similar agents may bepresent. When used to treat systemic diseases, the site of applicationon the skin is preferably changed periodically to avoid potential excesslocal concentration of steroids and possible overstimulation of the skinand sebaceous glands by androgenic metabolites of 5-DIOL.

[0075] 5-DIOL or derivatives can also be administered, by the oralroute, and may be formulated with conventional pharmaceutical excpients,e.g. spray dried lactose and magnesium stearate into tablets or capsulesor oral administration at concentrations providing easy dosage in arange from 0.050 to 2.5 grams per day per 50 kg of body weight.

[0076] The active substance can be worked into tablets or dragee coresby being mixed with solid, pulverulent carrier substances, such assodium citrate, calcium carbonate or dicalcium phosphate, and binderssuch as polyvinyl pyrrolidone, gelatin or cellulose derivatives,possibly by adding also lubricants such as magnesium stearate, sodiumlauryl sulfate, “Carbowax” or polyethylene glycol. Of course,taste-improving substances can be added in the case of oraladministration forms. The active substance can be also administered insolid dispersion state in appropriate carriers. Such carriers may bechosen from the group consisting of polyethylene glycols of molecularweight varying from 1000 to 20000 polyvinylpyrrolidone (Povidonepurchased from American Chemicals Ltd., Montréal, Canada).

[0077] As further forms, one can use plug capsules, e.g. of hardgelatin, as well as closed soft-gelatin capsules comprising a softeneror plasticized, e.g. glycerine. The plug capsules contain the activesubstance preferably in the form of granulate, e.q. in mixture withfillers, such as lactose, saccharose, mannitol, starches, such as potatostarch or amylopectin, cellulose derivatives or highly dispersed silicicacids. In solf-gelatin capsules, the active substance is preferablydissolved or suspended in suitable liquids, such as vegetable oils orliquid polyethylene glycols.

[0078] The concentration of active ingredients in the ointment, cream,gel or lotion is typically from about 2 to 20 percent preferably between5 and 15 percent and preferably between 5 and 10 percent (by weightrelative to the total weight of the lotion, cream, gel or ointment).Within the preferred ranges, higher concentrations allow a suitabledosage to be achieved while applying the lotion, ointment, gel or creamto a lesser surface area of the skin than would be possible at lowerconcentrations and allow more freedom in choosing the body parts towhich the ointment or lotion will be applied. For example, it is wellknown in the art that a compound which is capable of transdermalpenetration normally penetrates more efficiently at some points in thebody than in others. For example, penetration is very efficient on theforearm and considerably less efficient on the palms.

[0079] The lotion, ointment, gel or cream should be thoroughly rubbedinto the skin so that no excess is plainly visible, and the skin wouldnot be washed in that region until most of the transdermal penetrationhas occurred, preferably, at least 15 minutes and, more preferably, atleast 30 minutes after application.

[0080] A transdermal patch may be used to deliver 5-DIOL in accordancewith known techniques. It is typically applied for a much longer period,e.g. 0.5 to 4 days, but typically contacts active ingredients to asmaller surface area, allowing a slow and constant delivery of activeingredient.

[0081] A number of transdermal drug delivery systems that have beendeveloped, and are in use, are suitable for delivering the activeingredient of the present invention. The rate of release is typicallycontrolled by a matrix diffusion, or by passage of the active ingredientthrough a controlling membrane.

[0082] Mechanical aspects of transdermal devices are well known in theart, and are explained, for example, in U.S. Pat. Nos. 4,162,037,5,154,922, 5,135,480, 4,666,441, 4,624,665, 3,742,951, 3,797,444,4,568,343, 4,064,654, 5,071,644, 5,071,657, the disclosures of which areincorporated herein by reference. Additional background is provided byEuropean Patent 0279982 and British Patent Application 2185187.

[0083] The device may be any of the general types known in the artincluding adhesive matrix and reservoir-type transdermal deliverydevices. The device may include drug-containing matrixes incorporatingfibers which absorb the active ingredient and/or carrier. In areservoir-type device, the reservoir may be defined by a polymermembrane impermeable to the carrier and to the active ingredient.

[0084] In a transdermal device, the device itself maintains activeingrdient in contact with the desired localized skin surface. In such adevice, the viscosity of the carrier for active ingredient is of lessconcern than with a cream or gel. A solvent system for a transdermaldevice may include, for example, oleic acid, linear alcohol lactate anddipropylene glycol, or other solvent systems known in the art. Theactive ingredient may be dissolved or suspended in the carrier.

[0085] For attachment to the skin, a transdermal patch may be mounted ona surgical adhesive tape having a hole punched in the middle. Theadhesive is preferably covered by a release liner to protect it prior touse. Typical material suitable for release includes polyethylene andpolyethylene-coated paper, and preferably silicone-coated for ease ofremoval. For applying the device, the release liner is simply peeledaway and the adhesive attached to the patient's skin. In U.S. Pat. No.4,135,480, the disclosure of which is incorporated by reference, Bannonet al. described an alternative device having a non-adhesive means forsecuring the device to the skin.

[0086] Except for the higher dosage indications noted above (e.g.contraception), the target serum concentration of 5-DIOL is comparableregardless of whether 5-DIOL is being used as part of a combinationtherapy for treatment of menopause or is being used (by itself or incombination with antiestrogens, androgens, progestins, estrogens andinhibitors of 17β-hydroxysteroid dehydrogenase, aromatase inhibitors,inhibitors of gonadal sex steroid formation, LHRH agonists orantagonists, DHEA and/or DHEA-S) for the treatment of cardiovasculardiseases, osteoporosis, skin deterioration, monopause, vaginal atrophy,urinary incontinence, uterine cancer, ovarian cancer, osteoporosis,endometriosis, hypogonadism or dimished libido in accordance with theinvention or for the treatment of any conditions related to decreases orimbalances in the levels of sex steroids, in particular 5-DIOL and itsmetabolites.

[0087] 5-DIOL is particularly useful in treating conditions in which aminimal androgenic effect is desired since the androgenic effects of5-DIOL are lower than produced by DHEA for an equal estrogenic effectand the maximal androgenic effect achieved with 5-DIOL is lower thanthat achieved with DHEA. 5-DIOL is especially preferrd for the treatmentof conditions in women that respond to estrogen therapy (or therapy withan estrogen precursor, such as DHEA) since the androgenic action of5-DIOL is lower than that of DHEA and therefore, the potentialandrogenic or masculinizing effects are reduced, while the desiredestrogenc activity is provided. Moreover, in postmenopausal women, ingeneral, a greater estrogenic/androgenic ratio than that provided byDHEA is required.

[0088] Since 5-DIOL is a natural source of estrogens and androgens andthe secretion of this compound markedly decreases during aging (FIG.17), its replacement should have minimal unwanted side effects. Itsintrinsic estrogenic activity should compensate for the loss of estrogensecretion by the ovaries after menopause, an effect not achievable byDHEA. The invention is useful for many diseases wherein activation ofthe estrogen receptor will have beneficial effects, especiallyosteoporosis and menopausal symptoms, including vaginal atrophy,insomnia, irritability, cardiovascular disease, urinary incontinence,and loss of libido. In addition, the invention is useful for treatingand preventing diseases which are responsive to the activation of theandrogen receptor, e.g. bone loss, obesity, breast cancer, endometrialcancer, ovarian cancer, urinary incontinence, hypogonadism, loss oflibido, loss of muscle mass, loss of energy, insulin resistance andother aging processes. Further, 5-DIOL can be used to treat or preventany condition which responds favorably to an improvement in the overallbalance of circulating sex steroids, namely estrogens and androgens.

[0089] Conditions expected to respond to the treatments herein may bediagnosed in conventional ways. For example, the appearance of breastcancer is usually detected by self breast examination, clinical breastexamination by the physician and/or mammography. Endometrial cancer, onthe other hand, is usually diagnosed by endometrial biopsy. Both cancerscan be diagnosed and evaluated by standard physical methods well knownto those skilled in the art, e.g. bone scan, chest X-Ray, skeletalsurvey, ultrasonography of the liver and liver scan (if needed), CATscan, MRI and physical examination.

[0090] The onset of menopause is generally first recognized by theoccurrence of hot flashes. Further characterization of the menopause canbe determined in accordance with known techniques. See for Example, TheMenopause (Herbert J. Buchsbaurm, ed), Springer Verlag, New York (1983),pp. 222. Vaginal atrophy is often indicated by dyspareunia and vaginalinfections. Vaginal atrophy, hypogonadism, dimenished libido, insomnia,irritability, depression, and urinary incontinence are all characterizedin well-known ways. For the above-indicated disease, see, for example,Korenman, Stanley G, “Sexual Dysfunctions” in Williams Textbook ofEndocrinology, Jean D. Wilson and Daniel W. Foster, eds), W B SaundersCo., Philadelphia, pp. 1033-1048, 1992.

[0091] Bone density, on the other hand, can be measured by standardmethods well known to those skilled in the art, e.g. QDR (QuantitativeDigital Radiography), dual photon absorptiometry and computerizedtomography. Plasma and urinary calcium and phosphate levels, plaasmaalkaline phosphatase, osteocalcin, calcination and parathormoneconcentrations, as well as urinary hydroxyproline, deoxypyrrolidine, andcalcium/creatinin ratios are useful parameters of bone formation andresorption.

[0092] Loss of collagen or connective tissues in the skin oftenaccompanies aging, especially in persons over 50 years of age. It may beevidenced by wrinkling of the skin and/or low elasticity. Skin statuscan be assessed by visual inspection, palpation and, with moreprecision, by punch biopsy and standard histological examination.

[0093] The normal range of body weight is well known to those skilled inthe art, while cholesterol and lipoproteins are routinely measured bystandard techniques (Nestler et al. J. Clin. Endocrinol. Metab. 66:57-61, 1988 for references).

[0094] In addition, 5-DIOL is useful as a female contraceptive. In theprior art, female contraception usually involves administering anestrogen, which at increased circulating levels, reduces LHRH secretionfrom the hypothalamus which, in turn, decreases LH secretion from thepituitary. The resultant reduction in LH secretion decreased ovarianfunction, and in particular ovulation. Addition of a progestincontrolled the growth of the endometrium and transformed the vaginal andcervical secretions into an unfavorable environment for spermcapacitation and fertility.

[0095] In the present invention, 5-DIOL provides estrogen orcontraception while simultaneously and desirably providing minimallyincreased levels of androgens which will contribute to contraceptionsince androgens also inhibit LHRH and LH secretion. These androgens can,especially in women at perimenodause (as well as in postmenopausal womenwhen contraception is no longer required), provide much neededstimulation of bone formation and resistance to bone loss. In additionto being a weak estrogen by itself, the estrogens produced from theadministered 5-DIOL also contribute to reducing bone loss. As with otheruses discussed herein, use of 5-DIOL DIOL instead of a sex steroid (hereestrogen) avoids externally administering relatively high doses ofestrogens and this avoids giving such estrogens extensive access to alltissues, many of which do not require estrogens. By substituting 5-DIOL,estrogens and/or androgens are instead produced by natural processes inthe same tissues where estrogens and/or androgens are needed and thatnormally convert 5-DIOL to estrogens and/or androgens. The relativeproportions of estrogen and androgen also remain substantially atnatural levels in each specific tissue.

[0096] Because ovarian function is diminished by the contraceptiontechnique described herein, the ovarian production of estrogen andprogesterone will be decreased. Thus, a progestin (e.g.medroxyprogesterone acetate, megestrol acetate, norethynodrel,L-norgestrel) may be administered as part of the contraceptive method toprevent endometrial hypertrophy when high doses of 5-DIOL are needed.The progestin may be administered in a pharmaceutical composition thatincludes the 5-DIOL or separately. In certain embodiments, the progestinmay be administered intermittently every month for 12-14 days, or 12-14days every few months (e.g. every 2-5 months) or continuously, dependingupon the dose of 5-DIOL used which may well have no stimulatory effecton the endometrium at physiological dose. Progestin dosage may be in therange utilized in the prior art but is preferably lower for reasonsexplained below.

[0097] Since 5-DIOL is converted to estrogen in many tissues, it isunlikely that estrogen will need to be added to the contraceptivetherapy to compensate for the decreased estrogen production in theovaries. However, minimum doses can be given, if necessary. Preferreddosage of added estrogen, when used in the contraceptive method is anamount effective to achieve between 50 and 300 nanograms estradiol perliter or equivalent. Preferably the ratio of added estradiol to 5-DIOL(w/w) will range from 100:1 to 10,000:1, preferably, 200:1 to 5,000:1and especially 300:1 to 3000:1. As with added progestin, added estrogenmay be administered as part of a pharmaceutical composition thatincludes the 5-DIOL (or, where used, a prodrug of 5-DIOL) or separately.

[0098] In some embodiments, 5-DIOL, progestin and estrogen are alladministered, together or separately, as part of a combination therapy.A combination therapy results whenever a regimen of treatment elevatesblood levels of each active agent simultaneously. This simply requiresthat the active agents be administered sufficiently close in time thatelevated blood levels of these agents are concurrent.

[0099] The use of combination contraceptives containing estrogens andprogestins has not been shown to reduce the risk of breast cancer(Romiev et al., 1990, Cancer 66: 2253-2263). These data are ccnsistentwith a known mitogenic effect of both estrogen and progesterone onbreast cell epithelial proliferation, thus explaning a peak of cellproliferation at mid-luteal phase (Masters et al., J. Natl. Cancer Inst.1977, 58: 1263-1265; Anderson et al., 1982, Brit. J. Cancer 46 376-382).In fact, total breast cell proliferation rate in premenopausal womenusing contraceptives is not different from that of untreated cyclingwomen (Potter et al., 1988; Brit. J. Cancer 58: 163-170; Going et al.,1988; Am. J. Pathol. 130: 193-204). The androgenic component of 5-DIOLshould reduce this potential harmful effect of estrogens and progestins.

[0100] Osteoblasts (bone forming cells) contain the enzymes whichconvert 5-DIOL to estrogens and androgens. Therefore, 5-DIOL can be usedinstead of (or in addition to) androgen, estrogen, or DHEA in thetreatment or prevention of osteoporosis. Sufficient quantities ofandrogens are produced in the bone (by conversion of the administered5-DIOL) to stimulate bone formation and reduce bone loss. Furthermore,the low estrogenic activity of 5-DIOL and the estrogens produced fromthe administered 5-DIOL contribute to reducing bone loss.

[0101] Since bone mass density has been shown to be stimulated atparticularly low doses of androgens, 5-DIOL, which has a lower ratio ofandrogenic/estrogenic activity than DHEA should be able to have maximalbeneficial effects on the bone at a dosage which produces minimal risksof hyperandrogenism.

[0102] In addition, since 5-DIOL (or prodrugs thereof, if desired) istransformed to androgens and estrogens only by natural mechanismsexclusively in tissues that normally perform such transformationaccording to their local needs, side effects are greatly reduced oreliminated relative to externally administered active sex steroids ofthe prior art which have access to many tissues that neither produce norrequire a given androgen or estrogen. The physiological balance of sexsteroids in those tissues are thus not disturbed in accordance with thepresent invention, contrary to all hormone replacement therapies ofprior art. The relative ratio of andogens and estrogens produced fromthe 5-DIOL is also a substantially normal ratio instead of being anabnormally elevated ratio of one type of sex steroid as occurs when thatactive sex steroid is directly administered exogenously, thus causingexposure of all tissues, including those having no need for suchtherapy.

[0103] In one preferred treatment for menopausal symptoms, the inventionseeks to simultaneously maintain blood levels of 5-DIOL, androgens, andestrogens within normal premenopausal parameters. Without intending tobe bound by theory, it is believed that maintenance of appropriateprecursor levels will better enable natural enzymes, such as17β-hydroxysteroid dehydrogenase, 3β-hydroxysteroid hydrogenase,aromatase and 5α-reductase to regulate production of androgens andestrogens and to maintain them in a manner more closely resembling theirabsolute and relative levels prevailing prior to menopause. Hence, theinvention contemplates that not only estrogens but also androgens willbe kept in better balance. In fact, the target tissues possess theenzymatic machinery necessary to synthesize and inactivate androgensand/or estrogens according to local needs (Labrie, Mol. Cell.Endocrinol. 78, C113-C118, 1991).

[0104] As discussed above, 5-DIOL can be administered with estrogens.However, since compared to DHEA, a relatively higher proportion ofestrogens than androgens are produced and 5-DIOL is itself a weakestrogen, it should be possible to attain he desired level of estrogenswithout the addition of estrogens and without producing unwantedandroqenic side effects accompanying high levels of DHEA, a moreandrogenic compound. Similarly, since 5-DIOL is a weak estrogen,progestin therapy may not be required.

[0105] However, if it is determined that additional estrogens areneeded, the estrcgen and 5-DIOL may be administered simultaneously orseparately. In addition, it is necessary only that both the 5-DIOL andestrogen be administered in a manner and at a dosage sufficient to allowblood serum concentration of each to obtain desired levels. Inaccordance with the combination therapy of the invention, concentrationof the 5-DIOL is maintained within desired parameters at the same timethat estrogen concentration is maintained within desired parameters.Where estradiol is used, serum estradiol concentration should typicallybe maintained between 50 and 200 nanograms per liter, preferably between100 and 175 nanograms per liter and most preferably between 125 and 175nanograms per liter. Where another estrogen is used, serum concentrationmay be varied in a known manner to account for the known difference inestrogenic activity relative to estradiol and in order to achieve normalpremenopausal estrogen levels. A lesser concentration is needed, forexample, if Mestranol is used. Adequate serum estrogen levels can alsobe assessed by disappearance of the symptoms of menopause. Serumconcentration of the 5-DIOL is typically maintained between 4 and 10 nMfor women and between 10 and 20 nM for men or in some embodimentsbetween 4.0 and 7.0 nM or women or between 7.0 and 15 nM for men.

[0106] If estrogen is combined with 5-DIOL, it is preferably estradiol,but may be estrone sulfate or another compound which acts as on estrogenreceptor agonist directly or following proper conversion. Whenadministered separately, commercially available estrogen supplements maybe used, e.g., PREMARIN, available from Ayerst (St. Laurent, Québec,Canada). For typical patients, the appropriate dosage of estrogen toachieve desired serum concentrations is between 0.3 and 2.5 milligramsof PREMARIN per day per 50 kg of body weight when administered orally.In certain embodiments of the invention, the estrogen may be17β-estradiol administered percutaneously in a patch which is availablefrom CIBA under the name ESTRADERM wherein tne daily doses is between0.05 and 0.2 milligrams per day per 50 kg of body weight. For typicalpatients, the appropriate dosage of the sex steroid precursor 5-DIOL toachieve desired serum concentration of the precursor is between 0.10 and2.5 grams per day per 50 kg of body weight when administered orally.Other prodrugs will be administered at a dosage that depends on their invivo conversion rate to 5-DIOL. 5-DIOL may also be administeredtransdermally or transmucosally, as described in detail above, in asufficient amount to achieve target serum concentration.

[0107] In another embodiment, menopause is treated with 5-DIOL as setforth above, in combination with periodic administration of a progestinsuch as medroxyprogesterone acetate (e.g., Provera) which is preferablyadministered intermittently, e.g. at a dosage of 2-10 mg per day for 12consecutive days, said 12-day periods being spaced 20 days to 5 monthsapart. A combination therapy using 5-DIOL, an estrogen and a progestinmay also be used, preferably at the dosages discussed herein for eachcomponent.

[0108] The same doses of 5-DIOL will be used for all indications, exceptcontraception and prevention of ovarian and endometrial cancer whereserum levels of about to 15 nM 5-DIOL will be preferred.

[0109] For all other indications when androgens and/or estrogens areneeded, the usual dosage mentioned above will be used. Similarly, whenused in combination with an antiestrogen for the treatment or preventionof breast cancer, endometriosis, as other estrogen-sensitive disease,the same dose of 5-DIOL will be used. In some cases, where an aromataseinhibitor, an inhibitor of 17β-hydroxysteroid dehydrogenase, anandrogen, a progestin, an inhibitor of gonadal steroid formation, anLHRH agonist or antagonist is used, the same dose of 5-DIOL isrecommended.

[0110] The following examples demonstrate the androgenic and estrogeniceffects of 5-DIOL and provide a comparison of the relative activities of5-DIOL and DHEA. As discussed above, the preferential estrogenicactivity relative to androgenic activity of 5-DIOL compared to DHEA isshown.

[0111] Materials and Methods

[0112] Animals

[0113] Male and female Spraque-Dawley rats [Crl:CD (SD)BR]weighing225-250 g and 175-200 g respectively, were obtained from CharLes RiverCanada Inc. (St-Constant, Québec) and housed 2 per cage under a regimenof 14 h of light/day (lights on at 07:15 h). Animals received Purina ratchow and water ad libitum. The animal studies were conducted to the“Guideline for Care and Use of Experimental Animals”.

[0114] Treatment

[0115] The animals were randomly divided into the indicated groups (8and 10 rats per group for subcutaneous and topical administration,respectively). The animals of the appropriate groups were bilaterallyovariectomized (OVX) or orchiectomized (ORCH) under ether anesthesiawhile other rats were used as intact controls. DHEA and 5-DIOL obtainedfrom Steraloids (Wilton, N.H., USA) were dissolved in 50% ethanol-50%propylene glycol and applied twice daily (0.5 ml) on the dorsal skinarea (2 cm×2 cm) for 7 days starting on the day of OVX or ORCH. Forsubcutaneous administration, DHEA and 5-DIOL were dissolved in 0.5 ml10% ethanol−1% gelatin−0.9% NaCl and injected twice daily in the dorsalarea for 7 days starting also on the day of OVX or ORCH.

[0116] Seven days after starting treatment or approximately 12 h afterlast administration of the steroid, the animals were killed bydecapitation. Blood samples were collected individually and serum wasfrozen at −20° C. until assayed. Uteri, ovaries, ventral prostates,dorsal prostates and seminal vesicles were immediately removed, freedfrom connective and adipose tissue, weiched, frozen in nitrogen, andstored at −80° C. until assayed. Three rats from the indicated treatmentgroups were perfused with paraformaldehyde for in situ hybridization.

[0117] Steroid Analysis

[0118] Steroid extraction. Ethanol (5 ml) was added to 1 ml serum ancentrifugation at 2000×g performed for 15 min. The resulting pellet wasfurther extracted with 2 ml ethanol and, after a second centrifugationat 2000×g for 15 min, the two supernatants were combined. The suspensionwas recentrifuged as described above and the supernatant was decantedand combined with the previously obtained ethanol extracts. The organicsolvent was then evaporated under nitrogen and the residue was dissolvedin 1 ml water: methanol (95:5, v/v). The C-18 columns (Bound-Elut,Amersham, Bucks, U.K.) were conditioned by passing ccnsecutively 10 mlmethanol, 10 ml water and 10 ml methanol/water (5.95, v/v). The extractssolubilized in water: methanol (95:5, v/v) were then deposited on theC-18 columns. After washing the columns with 2 ml water: methanol (95:5,v/v) and 5 ml methanol: water (50:50, v/v), 5 ml methanol: water (85:15,v/v) were added to equate the non-conjugated steroids.

[0119] Chromatoqraphy on LH-20 columns and radioimmunoassay.Chromatography on Sephadex LH-20 columns (Pharmacia, Uppsala, Sweden)was performed as previously described (Bélanger et al., 1988). In brief,steroids were solubilized in 1 ml isooctane/toluene/methanol (90:5:5,v:v:v) and deposited on the LH-20 columns. Fractions were collected and,after evaporation of the organic solvent, the concentration of thevarious steroids was determined by radioimmunossay as previouslydescribed (Bélanger et al., 1980; Bélanger et al., 1988; Bélanger etal., 1990).

[0120] Preparation of the cDNA Probes

[0121] The plasmid containing the DNA fragment complementary to the mRNAencoding PBP-C1 was kindly provided by Dr. Malcom G. Parker (ImperialCancer Research Fund, London, United Kingdom). The 434-basepair Pst-Irestriction fragment of the PBP-C1 cDNA was purifed by electroelution(Bio-Rad electro-eluter, model 422, Bio-Rad, Richmond, Calif.; afterelectrophoresis on a 5% (wt/vol) polyacrylamide gel. The purifiedfragment was radiolabeled with [a-³⁵S]dCTPaS (Amersham, Oakville,Ontario, Canada) to high specific activity (10⁹ dpm/μg) bv the randomprimer method (Feinberg and Vogelstein, 1983).

[0122] Measurement of PBP-C1 mRNA Levels by in situ Hybridization

[0123] In situ hybridization of prostatic sections with the PBP-C1 probewas performed as described prevlously (Pelletier et al., 1988) In brief,rats were perfused with fixatIon buffer consisting of 4%paraformaldehyde in 0.1M phosphate buffer (pH 7.4). The ventralprostates freed from fat and connective tissue, were postfixed infixation buffer for 2 h at 4 C. and subsequently soaked in 0.05 M PBScontaining 15% (wt/vol) sucrose. Thereafter, the ventral prostates wererapidly frozen in isopentane chilled in liquid nitrogen. Multiple (sixto eight) 10 μM tissue sections from each ventral prostate were mountedon gelatin-coated glass slides. Prehybridization buffer contained 50%formamide, 5×SSPE (1×SSPE=0.18 M NaCl, 10 mM NaH₂PO₁, and 1 mM EDTA, ph7.4), 0.1% sodium dodecyl sulfate, 0.1% BSA, 0.1% Ficoll, 0.1% polyvinylpyrrolidone, 0.2 mg/ml yeast tRNA, 0.2 mg/ml denatured salmon testisDNA, and 2 μg/ml poly(A). The slides were hybridized in prehybridizationbuffer containing, in addition, 4% dextran sulfate and saturatingconcentrations (1.0-1.5×10⁷ cpm/ml) of the PBP-C1 cDNA probe for 48 h at37 C. The sections were then washed twice for 30 min. in 2×SSC(1×SSC=0.15 M NaCl and 0.015 M sodium citrate, pH 7.0), dehydrated, andexposed for autoradiography. To determine the amount of nonspecificbackground hybridization, prostatic sections for each treatment groupwere treated with pancreatin ribonuclease-A (20 μg/ml) for 1 h at roomtemperature before prehybridizing sections from rat brain, pituitary,kidney, and liver with the PBP-C1 probe. No specific hybridizazion couldbe observed (data not shown).

[0124] LH Radioimmunoassay

[0125] Serum LH was measured by double-antibody radioimmunoassay usingrat hormones (LH-I-5 for iodination; LH-RP-2 as standard), and therabbit antisera anti-r-LH-S-8, generously supplied by the NationalPituitary Program, Baltimore, USA.

[0126] Statistical Analyses

[0127] Radioimmunoassay data were analyzed using a program based onmodel II of Rodbard and Lewald (Rodbard, 1974). Plasma steroid levelsare shown as the means±SEM of duplicate determinations of individualsamples. In situ hybridization data were obtained as follows: for eachprostatic tissue section, 20 randomly selected areas measuring 0.25 mm¹(excluding aclnar lumen) were analyzed using an Image Research AnalysisSystem (Amersham, Arlington Heights, Ill.), and the mean optical densityvalue for each section was calculated. Data are shown as the means±SEMof 20 readings from 6-8 prostatic sections originating from ventral 3prostates. Statistical significance was measured according to themultiple range test of Duncan-Kramer (Kramer, 1956).

[0128] As shown in FIG. 1, DHEA and 5-DIOL produced similar stimulatoryeffects on uterine weight, an indicator of estrogenic activity. Inparticular, the administration of the 10 mg and 30 mg doses of DHEA and5-DIOL produced a comparable stimulation of uterine weight in theovariectomized rat, while 1 and 3 mg doses had no significant effect.However, at 100 mg, the highest dose used, 5-DIOL produced a greaterstimulatory effect with a maximal 52% reversal of the inhibitory effectof the ovariectomy as compared to the maximal 42% reversal produced byDHEA.

[0129] The effects of 5-DIOL and DHEA on serum LH are shown in FIG. 2.Serum LH is known to be a sensitive indicator of both androgenic andestrogenic activity based on the findings that serum LH increasesrapidly upon the removal of the predominant inhibitory feedback actionof sex steroids after gonadectomy in male as well as female animals(Ferland et al., In: Labrie, F., Meites, J., and Pelletier, G. (eds),.Hypothalamius and Endocrine Functions, pp. 191-209. New York: PlenumPress, 1976). At the 10 mg dose, 5-DIOL produced greater effects andcompletely reversed the potent stimulatory effect of ovariectomy to0.86±0.17 ng/ml while the corresponding dose of DHEA only caused a 61%(p<0.01) inhibitory effect. However, at higher doses, DHEA and 5-DIOLwere found to have similar effects, with the 30 mg and 100 mg doses,respectively, inhibiting serum LH levels by approximately 35% and 70%below the value found in intact control animals.

[0130] The effects on the circulating levels of the primary steriods andprecursors produced by the administration of 5-DIOL and DHEA are shownin FIGS. 3 through 7. In particular, as shown in FIG. 3, treatment withDHEA caused serum DHEA to increase from undetectable levels in controlovariectomized animals to 1.74±0.30 nM (p<0/01), 3.67±0.59 nM (p<0.01),12.9=3.69 nM (p<0.01) and 39.2±6.5 nM (p<0.01) after administration ofthe 3, 10, 30 and 100 mg dosages, respectively. On the other hand, arelatively constant but low level of serum DHEA was produced with thesame dosages of 5-DIOL.

[0131]FIG. 4 shows the serum levels of 5-DIOL which are produced afteradministration with 5-DIOL and DHEA. While at the lower doses, 1 and 3mg, 5-DIOL produced higher levels of 5-DIOL, at the higher doses, therewas no significant difference in the levels of 5-DIOL produced by 5-DIOLand DHEA.

[0132] The serum concentrations of 4-dione, testosterone anddihydrotestosterone (DHT) produced after administration of DHEA and5-DIOL are shown in FIGS. 5 through 7. The levels of serum 4-dione, anandrogenic indicator, produced by DHEA, ranged, depending on the dosage,from 30% to 125% higher than produced by 5-DIOL.

[0133] Consistent results were obtained with serum DHT and testosterone,both indicators of androgenic activity. Specifically, DHEA produced 30%to 125% higher serum DHT levels than 5-DIOL and at the highest dose,DHEA produced a 53% greater stimulatory effect on testosterone than thesame dose of 5-DIOL. Furthermore, the levels of serum DHT produced by5-DIOL remained substantially constant and relatively low across thedosage range.

[0134]FIGS. 3 through 11 are directed to the effects of DHEA and 5-DIOLon a variety of well-recognized androgen-sensitive parameters in theorchiectomized rat. FIG. 8 shows the effects on ventral prostate weight,wherein at the 10 mg dose, DHEA was able to reverse by about 75% theinhibitory effect of orchiectomy while a 150% higher dose (15 mg) of5-DIOL was only able to produce a 50% reversal of the effect ofcastration. In addition, DHEA was 1-fold more potent in increasingseminal vesicle weight, as shown in FIG. 9.

[0135] Furthermore, as shown in FIGS. 10 and 11, DHEA produced two tofive times the effect produced by 5-DIOL on the concentration of themRNAs encoding the C1 and C3 components of prostate binding protein(PBP) which, as discussed above, are precise indicators of androgenicactivity. Moreover, the maximal levels of C1 and C3 P3P mRNAs achievedwith the highest doses of 5-DIOL were only 17% to 37% of the levelsobtained by DHEA.

[0136]FIGS. 12 through 16 show the effects of subcutaneousadministration of DHEA and 5-DIOL on selected parameters describedabove. Since the two steroids were injected subcutaneously, theseresults provide a more direct measure of the relative estrogenic andandrogenic activities of DHEA and 5-DIOL under conditions of optimalbioavailability. In particular, as shown in FIG. 12, 5-DIOL, at thelowest dose used, namely 0.3 mg, reversed by 90% the effect of 1-weekovariectomy on uterine weight (an estrogen-sensitive parameter) whileDHEA, at the same dose, had no significant effect. However, at thehigher dosages, the maximal stimulatory effect achieved by the twosteroids was similar with a 2.8 to 2.9-fold stimulation. Furthermore, ascalculated from the doses giving half-maximal stimulation of uterineweight (−2.5 mg for DHEA and 0.5 mg for 5-DIOL), 5-DIOL is approximately5.0 times more uterotrophic than DHEA following subcutaneousadministration. In addition, as shown in FIG. 13, 5-DIOL was found to be5- to 7-fold more potent than DHEA in inhibiting the elevated serum LHlevels indicated by castration.

[0137] As shown in FIG. 14, the maximal stimulatory effects on prostateand seminal vesicle weights (androgen-sensitive parameters) obtainedwith 5-DIOL were about 70% of the values achieved with DHEA. However, ascalculated from the doses giving half-maximal reversasl of the effect oforchiectomy (ED₅₀), DHEA and 5-DIOL had approximately an equal potency(i.e. and ED₅₀ value of 1 mg). On the other hand, the ED₅₀ values ofmaximal DHEA and 5-DIOL effects were calculated at 2.5 mg and 1.2 mg,respectively, for an estimated 2-fold higher potency of 5-DIOL comparedto DHEA. Similarly, as shown in FIG. 15, for seminal vesicle weight, themaximal stimulatory effect of 5-DIOL was approximately 70% that of DHEAwith half-maximal reversals of the effect of orchiectomy estimated at2.5 and 1.2 mg, respectively, for DHEA and 5-DIOL for an estimated2-fold high potency of 5-DIOL. On the prostatic concentrations of C1 andC3 PBP mRNAs, 5-DIOL was about twice as potent as DHEA. FIG. 16 showsthe effects on serum LH concentration, with 5-DIOL being approximately10 times more potent than DHEA.

[0138] From the foregoing, it may be seen that, at every concentration,the ratio of estrogenic to androgenic effects provided by DHEA is moreheavily weighted toward androgenic effects than is that ratio for5-DIOL.

[0139] Although the present invention has been described in relation toparticular embodiments thereof, many other variations and modificationsand other uses will be apparent to those skilled in the art.

What is claimed is:
 1. A pharmaceutical composition comprising apharmaceutically acceptable diluent or carrier, and a therapeuticallyeffective amount of androst-5-ene-3β,17β-diol or a prodrug thereof. 2.The pharmaceutical composition of claim 1, further comprising atherapeutically effective amount of an estrogen.
 3. The pharmaceuticalcomposition of claim 1, further comprising a therapeutically effectiveamount of a progestin.
 4. The pharmaceutical composition of claim 2,further comprising a therapeutically effective amount of a progestin. 5.The pharmaceutical composition of claim 1, further comprising a compoundselected from the group consisting of dehydroepiandrosterone anddehydroepiandrosterone-sulfate.
 6. The pharmaceutical composition ofclaim 1, further comprising a pharmaceutically acceptable diluent orcarrier for percutaneous or transmucosal administration, wherein saidandrost-5-ene-3β,17β-diol or prodrug thereof is present at aconcentration between approximately 2 and 30 percent by weight relativeto the total weight of the pharmaceutical composition.
 7. A kitcomprising: a first container having therein androst-5-ene-3β,17β-diolor prodrug; and at least one additional container having therein atleast one active ingredient selected from the group consisting of aprogestin, an estrogen, dehydroepiandrosterone anddehydroepiandrosterone-sulfate.
 8. A therapeutic method for treating orreducing the likelihood of acquiring reduced or imbalancedconcentrations sex steroids, comprising the step of administeringtherapeutically effective amount of androst-5-ene-3β,17β-diol or prodrugthereof to a patient in need thereof.
 9. The method of claim 8, furthercomprising administering at least one additional agent selected from thegroup consisting of DHEA and DHEA-S, as part of a combination therapy.10. A method for treating or reducing the likelihood of acquiringsymptoms of menopause, comprising the step of administering atherapeutically effective amount of androst-5-ene-3β,17β-diol or prodrugthereof to a patient in need thereof.
 11. A method for treating orreducing the likelihood of acquiring vaginal atrophy, comprising thestep of administering a therapeutically effective amount ofandrost-5-ene-3β,17β-diol or a prodrug thereof to a patient in needthereof.
 12. A method for treating or reducing the likelihood ofacquiring hypogonadism, comprising the step of administering atherapeucally effective amount of androst-5-ene-3β,17β-diol or prodrugto a patient in need thereof.
 13. A method for treating or reducing thelikelihood of acquiring osteoporosis, comprising the step ofadministering a therapeutically effective amount ofandrost-5-ene-3β,17β-diol or prodrug to a patient in need thereof.
 14. Amethod for treating or reducing the likelihood of acquiring diminishedlibido, comprising the step of administering a therapeutically effectiveamount of androst-5-ene-3β,17β-diol or prodrug to a patient in needthereof.
 15. A method for treating or reducing the likelihood ofacquiring skin atrophy, comprising the step of administering atherapeutically effective amount of androst-5-ene-3β,17β-diol or prodrugto a patient in need thereof.
 16. A method for treating or reducing thelikelihood of acquiring urinary incontinence, comprising the step ofadministering a therapeutically effective amount ofandrost-5-ene-3β,17β-diol or prodrug to a patient in need thereof.
 17. Amethod for reducing the likelihood of acquiring ovarian cancer,comprising the step of administering a therapeutically effective amountof androst-5-ene-3β,17β-diol or prodrug to a patient in need thereof.18. A method for reducing the likelihood of acquiring uterine cancer,comprising the step of administering a therapeutically effective amountof androst-5-ene-3β,17β-diol or prodrug to a patient in need thereof.19. A method for treating or reducing the likelihood of acquiring skindryness, comprising the step of administering a therapeuticallyeffective amount of androst-5-ene-3β,17β-diol or prodrug to a patient inneed thereof.
 20. A method of contraception, comprising the step ofadministering a therapeutically effective amount ofandrost-5-ene-3β,17β-diol or prodrug to a patient in need thereof. 21.The method of claim 20, further comprising administering atherapeutically effective amount of an estrogen.
 22. The method of claim20, further comprising administering a therapeutically effective amountof a progestin.
 23. A method for treating breast cancer, uterine cancer,ovarian cancer or endometriosis comprising the step of administering atherapeutically effective amount of androst-5-ene-3β,17β-diol or prodrugthereof to a patient in need thereof in association with at least one ofthe following compounds: antiestrogen, androgen, DHEA, inhibitor ofaromaase, inhibitor of 17β-hydroxysteroid dehydrogenase, LHRH agonist orantagonist.
 24. A method for treating breast cancer, uterine cancer,ovarian cancer or endometriosis comprising the step of administering atherapeucically effective amount of dehydroepiandrosterone (DHEA) to apatient in need thereof in association with at least one of thefollowing compounds: antiestrogen, androgen, inhibitor of aromatase,inhibitor of 17β-hydroxysteroid dehydrogenase, LHRH agonist orantagonist.
 25. A method or treating or reducing the likelihood ofacquiring an indication selected from the group consisting of obesity,cardiovascular disease, atherosclerosis, insulin resistance, loss ofmuscle mass, loss of energy or fatigue, loss of memory, Alzheimerdisease, comprising administering a therapeutically effective amount ofthe pharmaceutical composition of claim
 1. 26. A transdermal patch whichcontinuously delivers androst-5-ene-3β,17β-diol or prodrug, said patchhaving a means for attaching to skin, a reservoir for said compound anda means for conducting said compound into contact with skin.
 27. Thepharmaceutical composition of claim 1, further comprising apharmaceutically acceptable diluent or carrier for oral administration,wherein said androst-5-ene-3β,17β-diol or prodrug ofandrost-5-ene-3β,17β-diol is present at a concentration betweenapproximately 5 and 99 percent by weight relative to the total weight ofthe pharmaceutical composition.